HOW HE SEES IT Med schools must meet needs of aging citizens

By R. EDWARD HOWELL KNIGHT RIDDER/TRIBUNE CHARLOTTESVILLE, Va. -- Nearly 3,000 people lined up at a remote fairground on the Virginia-Kentucky border in late July to receive free healthcare from medical professionals, many of whom traveled hundreds of miles for this annual event. For the patients, the event was a rare opportunity to receive top-notch medical care and probably their only chance to see a specialist, because of shortages in their communities. Across America, shortages have developed in such crucial specialty areas as nephrology (kidney) and geriatric medicine that undoubtedly will affect the nation's burgeoning population of baby boomers. Health Affairs journal reports that today's ratio of one kidney specialist for every 40 to 60 end-stage renal disease patients will dwindle to one for 120 patients by 2010. Academic medical centers, like the one I head, already have specialists working at full capacity, and the demand will not decrease any time soon. With baby boomers now the largest percentage of the U.S. population -- and starting to turn 65 in 2011 -- the need for such specialists will continue to grow. What's more, the nation hasn't yet decided that more specialty training is needed. Once we do, it will take years to train new specialists. Managed care The reason for our predicament is not hard to trace. Twenty years ago, when managed care was first proposed, the assumptions behind it seemed unimpeachable. Baby boomers were in the prime of life. It seemed reasonable to suppose that much of what ailed them could be treated -- and treated well -- by general practitioners. Managed care advocates offered a straightforward solution: create a more equal balance between generalists and specialists -- and be more selective in granting access to specialists. By managing demand, you decrease costs and provide more effective care without having to add significantly to the supply of doctors. In 1994, the Council on Graduate Medical Education (COGME), a national advisory body that makes policy recommendations about the adequacy of the supply and distribution of physicians, recommended that total residents in training be limited to 110 percent of the 1993 graduating class of U.S. medical students -- and that half of these physicians be generalists. Medical schools and teaching hospitals were quick to respond -- and even to overrespond. They reduced the size of specialty programs, trained increasing numbers of generalists and checked the growth of the profession. Simultaneously, between 1990 and 2000, the number of people in the 50-54 age group grew 55 percent. Just as the baby boomers began to require more specialty care, we certified more generalists. We now find ourselves in a situation where the demand for specialty physicians -- and for physicians of all kinds -- is inadequate to the supply. Adding to the dilemma is the fact that many of our specialists are closing in on retirement at the same time that dramatic advances in computerized and molecular medicine make the need for specialists even more pressing. The answer is not simply to swing the pendulum back in the direction of specialty care -- though we obviously need more specialists. It will not serve us well to find ourselves a decade from now with an inadequate supply of generalist physicians. COGME has now reconsidered its former position and is recommending that medical schools expand the number of graduates by 3,000 per year by 2015. A first step is to give our teaching hospitals the resources to reinvigorate their specialty programs. Ongoing analysis The second step is to create a more dynamic mechanism for ongoing analysis and forecasting specific physician workforce needs, perhaps under the direction of COGME or an organization created for this specific purpose. A program that continuously monitors demographic shifts, advances in medical science, and the rapidly changing roles of physician and non-physician clinicians, among other issues, would give us a more responsive mechanism to fine tune the size and distribution of our educational effort in anticipation of likely demand. Certainly these proposals will cost money, but they represent our best bet to restrain rising healthcare costs as managed care proposed to do in the first place. Ultimately, managed care and our healthcare policy in general were destined to fail because the focus primarily was on managing demand. To maintain the healthcare market in a state of dynamic equilibrium, we need to think about and manage supply as well. X R. Edward Howell is vice president and CEO of the University of Virginia Medical Center.